HomeMy WebLinkAbout06030014-Application
CONTRACTOR
INFORMATION:
APPLICANT
INFORMATION:
TYPE of WORK:
PROPERTY
OWNER
INFORMATION:
INSPECTION
INFORMATION:
City of Carmel/ Clay Township -# 060300/ Lj
APPLICATION FOR ELECTRICAL INSPECTION
NAME
. OmN / Z/ec.J-:e /e-
PHONE
,
FAX I
76S-:"7s-J31f/ .
16S -&, 75-1/'/113
Street Address Oty c' State ZIp
02691 :J dOO W 7(10)1/ 7d. t.j(pO 7 Z
NAME /-1T"'.7SldN 'J)eL). Co.J:;J<Z... CONTAcrPHONE: 3/7- 7/(P-Z'193
JdJJ/! &10Md'S
Property Owner
(or agent)
Contractor
Representative
~
OR
RESIDENTIAL:
v
COMMERCIAL:
PROPERTY OWNER NAME(S): /1 _ PHONE:
Lmvt;S/t::W'1>>I/. Lo.J--,vC !3'-/t.-J- 70/7
STRE//32 S ~ ud 2~ ;:;:,'~ . ;:;
STREET ADDRESS (INSPEcnON LOCATION): CIty State
W.a-S{, ~cI --,yj\/
ZJp
'-/(;{) 3
. ZJp
LfIPO 1t/
DATE OF INS E
3
TYPE OF IMPROVEMENT:
TIME OF INSPECTION: 4fY7
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
o UPGRADE SERVICE: From
to
DYES
o NO
o UPGRADE PANE~ BOARD(S) [AFCI BREAKERS REQUIRED]
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS ORM IS COMPLETE AND ACCURATE.!
.[ctM~
nature
Jd h f7 f'J/)..; /rICC/>
PRINT
ril NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
3// /O~
. DATE' .'
o CONNECTION or RECONNECTION TO A RELOCATED
. STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach maD of insDection location) .
/J1~ 130:<lJ( i'y; d)1--d~ tl-t;), Wa.JJ, /lJrf7L{/... $/ch d6~cuvLJ
t:C~{)~~~' .
FEES: $ 96.25 for Commercial Inspections; $ 53.50 for Residential Inspections
. S:Permlts/Forms/Electrlcal Application Oct 2003
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